Gary Cheuk
Historical Perspective
The word “geriatrics” comes from two Greek words “iatros”, a healer, and “geros”, an old man. Ignatz Nascher was the first to coin the word geriatrics and advocate for the formation of a new branch of medicine for old people [1]. In 1935 Dr.
Marjory Warren, a physician and deputy medical director of West Middlesex Hospital, Isleworth, Middlesex, was given the responsibility for the adjacent workhouse with 714 chroni- cally ill patients [2]. She systematically reviewed them and was able to discharge a large number to their homes or resi- dential care by providing active rehabilitation and proper equipment [3]. She attributed this high number of chronically ill to a number of reasons, including poor diagnosis, the lack of proper treatment and supervision and the lack of multidis- ciplinary teamwork [2]. This was the beginning of the first geriatric unit in the United Kingdom based upon comprehen- sive assessment and early rehabilitation by a multidisciplinary team [4] and the development of geriatric medicine as a spe- cialty [5]. In her writings, Dr. Warren stressed the importance of multidisciplinary teams, early ambulation, active involve- ment in daily activities [6] and a holistic approach to older patients [7]. This still forms the basic principles of CGA today.
Comprehensive Geriatric Assessment
Comprehensive geriatric assessment (CGA) is a process where the complex physical, functional, cognitive, psycho- social and rehabilitation needs of a frail older person are identified and a plan of management instituted. Geriatric evaluation and management (GEM) describes a similar pro- cess with a specific therapy component as part of the man- agement plan. A team-based approach is essential with input
from general practitioners, geriatric medicine specialists, physiotherapists, occupational therapists, social workers, speech therapists and, where applicable, staff working in aged care facilities and other community care staff. CGA has been applied in a number of settings. These include inpatient geriatric and management unit (GEMU), inpatient consulta- tive service such as orthogeriatric service, domiciliary care, outpatient service and in chronic aged care facilities. The practice of CGA varies according to the setting. For exam- ple, in the primary care setting, the process could be initiated by the general practitioner with input from a practice nurse.
In the acute hospital setting, older persons in GEMU often have blanket referrals to the multidisciplinary team, which includes geriatricians, physiotherapists, occupational thera- pists and social workers with other personnel involved as appropriate. In the outpatient setting, it is often performed by geriatricians or nurse practitioners, whilst in the domiciliary setting, older persons are often assessed by a single aged care worker with the involvement of other disciplines where appropriate. CGA commonly involves a number of contacts with the subjects over a period of time, that is, it is a process rather than a single interaction with one or more health-care providers. It is imperative that frail older persons and their families and significant others are central to the process of assessment and care planning. Indeed, no assessment is com- plete without involving the older persons’ families and carers in the identification of issues and in the formulation of care plans. As this process often involves more than one health- care professional, it is important that documentation is struc- tured and presented in a way which enables the effective transfer of clinical information across different settings and between service providers.
CGA was promoted and practised based on the observa- tion of and advocacy by pioneers in the practice of geriatric medicine before there was any credible evidence to support its cost-effectiveness, similar to the development of coronary care units in medicine. There is significant variation in the model, composition of the multidisciplinary team and inten- sity of intervention. It is practised in a number of different
G. Cheuk (*)
Geriatric Medicine, Rehabilitation and Aged Care Service, Blacktown-Mt Druitt Hospital, Blacktown, NSW, Australia e-mail: [email protected]
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care settings, such as inpatient geriatric evaluation and man- agement unit (GEMU), inpatient geriatric consultative ser- vice (IGCS), inpatient rehabilitation, domiciliary assessment programme and outpatient service. This makes the evalua- tion of the effectiveness of CGA very challenging.
A meta-analysis of 28 trials by Stuck et al. in 1993 showed that the odds ratios of remaining at home versus death or admission to a nursing home are higher for subjects who were randomised to comprehensive geriatric assessment in GEMU, hospital post-discharge assessment and domiciliary assessment [8]. There is also some evidence that GEMU improves physical and cognitive function in follow-up, but there is no clear evi- dence of benefit in mortality and prevention of hospital admis- sions [8]. Covariate analysis showed that programmes with direct control over interventions and long-term ambulatory care follow-up are more likely to be effective [8]. Patients man- aged in inpatient geriatric assessment units are less likely to experience decline in health- related quality of life at 3 months [9]. In the latest updated review in the Cochrane Database, older patients who received CGA are more likely to be alive and living in their homes after follow-up of 3–12 months. CGA decreases the likelihood of participants being admitted to nurs- ing homes but makes no difference in their mortality, physical or cognitive function at follow-up [10].
In the care of the oldest old, CGA is being employed increasingly in the determination of appropriate medical intervention. CGA has been shown to influence treatment decisions in the management of solid-organ malignancy in 21–49% of cases [11]. Functional impairment, malnutrition and co-morbidities are independently associated with che- motoxicity and/or survival [11]. CGA was also shown to be useful in a small study to predict death or hospitalisation within 3 months of transcatheter aortic valve implantation [12]. CGA can also be used in the review of treatment and identify potential subjects for deprescribing in the oldest old who are most at risk of adverse drug events and reactions.
Instruments Used in CGA
It is beyond the scope of this chapter to review instruments used in CGA. There are certainly many validated instruments to screen and document cognitive function, abilities to per- form personal and instrumental activities of daily living, behavioural and psychological symptoms, depression, falls risk and continence. The choice of instruments should take into consideration of the patient’s education and cultural back- ground, settings where the assessment occurs, the nature of presentation and the purpose of the assessment. For example, it would be inappropriate to use Folstein’s mini-mental exami- nation for patients with little education, from a cultural and linguistic diverse background or suspected frontal lobe impair- ment. Whilst it is not mandatory to do so, the benefit of using
structured instruments in the assessment of older persons is to enable fairly uniform documentation and transfer of informa- tion and may assist in avoiding duplication of assessment, which often is a cause for complaint when an older person is assessed by a number of health professionals (Table 5.1).
Screening in the Elderly
According to the World Health Organization (1974), the pur- pose of screening in geriatrics is preventive care, “to keep the elderly in good health and happiness in their own houses for as long as possible” [24]. To achieve this, the initial assess- ment and screen should determine any acute and chronic medical issues and review of their treatment, levels of func- tional and psychosocial well-being, home environment and the strengths and deficits in an individual as well as the pres- ence of harmful life-style behaviours such as smoking, exces- sive alcohol use or sedentary life-style followed by the development of intervention or management plan. A review of the vaccination status should also be performed. The sub- ject should also be encouraged to develop or review existing advance care plans. There is paucity of data in the benefit of specific disease-oriented screening in the oldest old. The goal of treating the oldest old should be to preserve function and improve the quality of life rather than to prolong life [25].
Table 5.1 Domains and examples of instruments used in CGA
Domains Context Instruments
Basic activities of daily living (ADL)
Ability to self-care, basic mobility and continence
Barthel index [13]
Instrumental ADL
Ability to shop, cook, housekeeping and manage finance
Lawton and Brody [14]
Social activity and support
Extent of social network and engagement in community activities
Lubben social network scale [15]
Cognition Alertness, orientation, attention and ability to perform complex tasks
Folstein mini-mental state examination [16], Addenbrooke’s cognitive examination [17, 18], Rowland’s universal dementia assessment scale [19]
Mental health The degree the person feels depressed, anxious
Geriatric depression scale [20]
Mobility Assessment of gait, balance and risk of falls
Tinetti performance- oriented mobility assessment [21], timed up and go test [22]
Nutrition Current nutritional status and risk of malnutrition
Mini-nutritional assessment [23]
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With increasing years, there is an increasing frequency of disorders involving all organ systems resulting in increasing co-morbidity. The presence of disability also increases with age, with 40% of those aged between 65 and 69 reporting a disability. This rises to 88% in those aged 90 or over [26].
The syndrome of frailty, which can be defined as a state of increased vulnerability to stressors due to decreased physio- logic reserves, also increases with ageing with as many as 40% of people aged 80 or over are frail [27]. The combina- tion of increasing co-morbidity, frailty and disability of older persons contributes to the complexity and often difficulties in prioritising intervention in an older person. The fragmen- tation of the health care, long-term care and social welfare systems and the prevalence of ageism contribute to the chal- lenges in addressing the care needs of the oldest old.
Primary care physicians are the best placed to commence comprehensive geriatric assessment as well as to co-ordinate the implementation of care plans. In a large majority of the elderly, the care provided is by the primary care physicians.
Many of the elderly are brought to assessment by their fami- lies. It is well known that it is the family member who has noticed functional deficits before the deficits are evident by normal psychometric tests in the elderly. The American College of Physicians recommends that primary care physi- cians incorporate within their routine medical management of older patients procedures for measuring functional deficits [28]. The Affordable Care Act in the United States also pro- vides for yearly “wellness” examination with key preventive services to enrollees [25]. In Australia, the Medicare Benefits Schedule has set payments for primary care physicians for annual assessments of people aged 75 or over including medical, functional, psychological and social/environment components [29]. Primary care physicians should also screen for the presence of geriatric syndromes such as cognitive impairment, falls/immobility, depression and incontinence.
The World Health Organization has developed a toolkit for the use by primary care physicians which covers the main elements of health screening for older persons [30].
Following the screening by the primary care physicians, a referral to a specialist aged care service may be required especially for persons who suffer from one of the geriatric syndromes, are frail or suffer from multiple co-morbidities.
Geriatric Assessment Team
This is followed by a referral to a geriatric assessment team (a multidisciplinary team), which determines the current sta- tus – physical, mental and psychosocial health:
(i) His or her ability to function independently.
(ii) Living arrangements.
(iii) Access to and needs for support services.
(iv) Identify current problems and predict course of illness and likely problems.
(v) Establish connection between older person and resources.
(vi) Follow up and ongoing monitoring and to determine what extent the connection between the older person and resources has or has not addressed the problem.
The OUTCOME of the comprehensive assessment is the development of the ‘CARE PLAN’ which lists the problems identified and suggests specific interventions (e.g. specialist services) or actions required (Algorithm 5.1).
Case Study
An 88-year-old man who lives at home with his wife suffers from dementia. He is independent in his personal activities of daily living but requires assistance with housekeeping and meal preparation. He has a history of ischaemic heart disease with previous coronary artery stent, Type II diabetes mellitus and hypertension. He was being treated with chemotherapy (docetaxel) and immune checkpoint inhibitor (ipilimumab) therapy for metastatic carcinoma of prostate from October last year, with a pretreatment prostate-specific antigen (PSA) level of >500 ng/ml. This was complicated by immune colitis, requiring high-dose prednisone, which in turn caused instabil- ity of his diabetes, necessitating the commencement of insulin.
He presented with decreased oral intake and mobility.
He was asymptomatic of his known skeletal metastases but since the commencement of chemotherapy has been complaining of paraesthesia of his limbs and altered taste.
Clinical Relevance
Comprehensive geriatric assessment by a multidisci- plinary team is the cornerstone of geriatric medicine.
The incidence of multiple co-morbidities, frailty and disability increases with age and is a predictor of poor outcomes.
Comprehensive geriatric assessment increases the likelihood of an older person being alive and living in their own homes.
The older person and his/her significant other should be central to the process of assessment.
Primary care physicians and health care professionals are best placed to screen for geriatric syndromes, provide life-style counselling and make referrals to specialist aged care service.
Comprehensive geriatric assessment is being applied in other fields of medicine to determine appropriate therapy.
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Algorithm 5.1 A practical approach to comprehensive geriatric assessment and management. (Information sources: Ward, 2017; Ellis et al. [10];
Yesavage et al. [20]; Dupee [31]; Mohd-Sidik et al. [32]; Brit Geriatr Soc [33]; Walston and Fried [34])
REFERRAL General Practitioner
Community
worker In Hospital Outpatient Emergency
INDICATIONS For REFERRAL
medical comorbidities such as heart failure and cancer, specific geriatric conditions such as dementia, falls, choosing where to live, recent and impending life changes rehabilitative status, nutritional status and needs and with multiple medical problems amongst others
CGA COMPREHENSIVE GERIATRIC ASSESSMENT
TEAM geriatrician, aged care assessment team, physiotherapist, occupational therapist, dietician, psychologist and social worker
AREAS for
ASSESSMENT SOME SELECTED AREAS: Gait, balance and falls, Frailty and nutritional needs; Mood disorders;
Functional status, Cognition and dementia; House &Transport facilities
ASSESSMENT
Balance Gait and Falls Balance-for postural control i. tandem gait
ii. one-legged stance (‘stalk’ stance), Berg’s Balance test iii. Romberg test iv. Sternal nudge Gait
Walking ability-initiation of gait, step height, step length, step symmetry, path deviation, trunk stability, walk stance and turning.
Frailty and nutritional needs Timed get up and Go/grip strength or SARC-F Check
BP,BMI Nutritional status Cognitive &, psychological status Physical-ADLs, IADLs Social
Functional status BADLs-toileting, bathing, dressing, grooming, feeding IADLs-housework, phoning, shopping, driving AADLs- preparing meals, managing finances.
laundry, taking medications
Cognition/dementia Physical &
Neurological examination Psychometric test
Assessment of functional capacity DSM-5 Criteria
Memory impairment
One of either apraxia, aphasia or apraxia Disturbance of executive function Impairment of social and occupational functioning Decline from previous functioning FBC, UEC, LFT, Serum B12, TSH, folate, BSL, MSU Structural imaging
Mood Disorders
Geriatric Depression Scale (GDS) has a long and short forms. Short screening tool for depression consisting of two questions with a
‘help’ question (TQWHQ) [ ].
CARE PLAN Case management
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On assessment, he was stable haemodynamically and cognitively intact. He was found to be malnourished with decreased mobility. There was evidence of peripheral neu- ropathy and chronic venous stasis. He was cognitively intact.
Due to his impaired mobility, he has become functionally incontinent or both urine and faeces. His repeat PSA was 150 ng/ml.
Issues: Appropriateness of continuing therapy for meta- static disease, which is causing non-specific symptoms but has significant side effects.
Outcomes: Patient’s medications were rationalised, and he was given rehabilitation following which will be reviewed by his oncologist to seek further information of prognosis with or without treatment.
Multiple Choice Questions (MCQs)
1. The following in relation to comprehensive geriatric assessment are true, EXCEPT:
A. Comprehensive geriatric assessment is carried out most successfully by a multidisciplinary team.
B. Medicare Benefits Schedule does not have set require- ments for payments to primary care physicians for assessments.
C. The outcome of the comprehensive assessment is the development of the care plan.
D. A comprehensive screen consisting of a group of tar- geted instruments would be useful to assess functional deficits methodically.
Answers to MCQs 1. B
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